Provider Demographics
NPI:1598875486
Name:BARRY C PEVNER MD PA
Entity Type:Organization
Organization Name:BARRY C PEVNER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEVNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-347-1360
Mailing Address - Street 1:601 N FLAMINGO RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1010
Mailing Address - Country:US
Mailing Address - Phone:954-347-1360
Mailing Address - Fax:954-436-8024
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 303
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1010
Practice Address - Country:US
Practice Address - Phone:954-557-5407
Practice Address - Fax:954-436-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063488300Medicaid
FL063488300Medicaid